Lessons learnt and future directions in managing dialysis access during the COVID 19 pandemic: Patient and provider experience in the United States.

BACKGROUND: The COVID 19 pandemic adversely impacted delivery of preventive, routine, urgent, and essential care worldwide. Dialysis access care was particularly affected due to the lack of specific guidelines regarding procedures for its creation and maintenance. Early guidance by Centers for Medicare and Medicaid was inadvertently interpreted as guidance to stop dialysis access procedures. Prompt action by professional societies was needed to furnish detailed guidance to establish essential nature of these procedures. METHODS: The American Society of Diagnostic and Interventional Nephrology (ASDIN) issued a joint statement with Vascular Access Society of the Americas (VASA) - "Maintaining Lifelines for ESKD Patients" to clearly establish the role of vascular access as a lifeline for ESKD (End Stage Kidney Disease) patients and the importance and urgency of its timely management. ASDIN also conducted a survey in mid-2020, that was administered to the ASDIN database as well as shared with the general public via the organization's social media platforms. The respondents reported their experiences in the care of dialysis access, practice patterns and the utility of the ASDIN-VASA statement during the COVID 19 pandemic. RESULTS: Of the 2030 individual surveys sent, 581 were opened and 53 (9.1%) responses were received from different parts of the country and from different practice settings. ASDIN COVID 19 triage document was frequently utilized and 83% of respondents found the document valuable. The survey also revealed multiple obstacles, including logistical and financial issues that led to significant disruption of services. CONCLUSIONS: The care of dialysis access was significantly affected in the United States during the COVID 19 pandemic due to multiple reasons. ASDIN actions provided valuable specific guidance regarding and explored barriers to dialysis access care. We describe those results and discuss strategies to prevent COVID 19 transmission with innovative strategies of providing access care. Individualized decision making is of essence when considering dialysis access procedures.

Variable-Intensity Simulated Team-Sport Exercise Increases Daily Protein Requirements in Active Males.

Protein requirements are generally increased in strength and endurance trained athletes relative to their sedentary peers. However, less is known about the daily requirement for this important macronutrient in individuals performing variable intensity, stop-and-go type exercise that is typical for team sport athletes. The objective of the present study was to determine protein requirements in active, trained adult males performing a simulated soccer match using the minimally invasive indicator amino acid oxidation (IAAO) method. After 2 days of controlled diet (1.2 g⋅kg-1⋅day-1 protein), seven trained males (23 ± 1 years; 177.5 ± 6.7 cm; 82.3 ± 6.1 kg; 13.5% ± 4.7% body fat; 52.3 ± 5.9 ml O2⋅kg-1⋅min-1; mean ± SD) performed an acute bout of variable intensity exercise in the form of a modified Loughborough Intermittent Shuttle Test (4 × 15 min of exercise over 75 min). Immediately after exercise, hourly meals were consumed providing a variable amount of protein (0.2-2.6 g⋅kg-1⋅day-1) and sufficient energy and carbohydrate (6 g⋅kg-1⋅day-1). Protein was provided as a crystalline amino acids modeled after egg protein with the exception of phenylalanine and tyrosine, which were provided in excess to ensure the metabolic partitioning of the indicator amino acid (i.e., [1-13C]phenylalanine included within the phenylalanine intake) was directed toward oxidation when protein intake was limiting. Whole body phenylalanine flux and 13CO2 excretion (F13CO2) were determined at metabolic and isotopic steady state from urine and breath samples, respectively. Biphasic linear regression analysis was performed on F13CO2 to determine the estimated average requirement (EAR) for protein with a safe intake defined as the upper 95% confidence interval. Phenylalanine flux was not impacted by protein intake (P = 0.45). Bi-phase linear regression (R2 = 0.64) of F13CO2 resulted in an EAR and safe intake of 1.20 and 1.40 g⋅kg-1⋅day-1, respectively. Variable intensity exercise increases daily protein requirements compared to the safe intake determined by nitrogen balance (0.83 g⋅kg-1⋅day-1) and IAAO (1.24 g⋅kg-1⋅day-1) but is within the range (i.e., 1.2-2.0 g⋅kg-1⋅day-1) of current consensus statements on general recommendations for athletes. CLINICAL TRIAL REGISTRATION: This trial was registered June 18, 2015 at http://clinicaltrials.gov as NCT02478814.

Dilator-assisted banding for managing complications associated with excessive hemodialysis access flow.

Excessive hemodialysis access flow can be associated with serious complications, such as ischemic steal syndrome and heart failure. Among the therapeutic approaches, endoluminal balloon-guided banding has the advantage of being minimally invasive. However, it requires fluoroscopic guidance. We here report a simpler approach, Dilator-assisted Banding (DAB), in which over-the-wire vascular dilators of known diameters are used as endoluminal-guides to achieve precision banding with or without fluoroscopic guidance. The dilators used are 10, 12, and 14 French, corresponding to 3.3, 4.0, and 4.7 mm in diameter, respectively. Of the seven treated patients with ischemic steal syndrome, three were males, mean age was 67.7 ± 16.3 years, five were diabetics, all were hypertensive, five had fistulas, and two had grafts. Mean age of hemodialysis accesses was 17.2 ± 8.4 months. Three patients had banding without fluoroscopic guidance, including two performed during fistula vein superficialization and basilic vein transposition. With follow-up of 2-12 months, all hemodialysis accesses remained functional. Six patients had complete resolution and one reported marked improvement of ischemic symptoms. In summary, DAB is a simple, effective, and economical flow-reduction alternative for managing ischemic steal syndrome and potentially other complications associated with excessive access flows. In addition, it can be safely performed without fluoroscopic guidance.

An alternative approach to a totally occluded subclavian vein in a malfunctioning arteriovenous fistula.

Endovascular therapy is useful in the treatment of a malfunctioning or nonmaturing arteriovenous (AV) fistula. When a standard trans-access approach fails, alternative approaches can be attempted. A patient with a malfunctioning fistula is presented describing the use of a successful transjugular approach after an unsuccessful trans-fistula attempt. The merits of this alternative method are discussed. An alternative means of treating a malfunctioning dialysis AV fistula may help increase the prevalence of AV fistulae in the hemodialysis population.